UNIQA Travel Medical Insurance Application (for CTU in Prague)
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Personal information
CTU ID number
Optional for newcomers. You can find your CTU ID number after the login to User Map Portal (https://usermap.cvut.cz/) or User data Base FEE CTU in Prague (https://udb.fel.cvut.cz/) – see your profile page.
Name *
Like in your travel document
Surname *
Like in your travel document
Date of Birth *
MM
/
DD
/
YYYY
Pasport no. *
... or other travel document
E-mail *
Contact address in the Czech Republic
In case your have booked the accommodation in CTU dormitory, here you can find the full address of all CTU dormitories: https://www.suz.cvut.cz/en/dormitories
Street Name, no. *
City *
Postal Code *
Insurance options
Tariff *
Start Date *
Start of the insurance contract/services
MM
/
DD
/
YYYY
End Date *
Start of the insurance contract/services
MM
/
DD
/
YYYY
Notes
*
In accordance with the Act No. 101/2000 Coll., on the Protection of Personal Data, as amended, I hereby grant my free and unconditional consent for processing of my personal data to the Czech Technical University in Prague – Faculty of Electrical Engineering, VAT: CZ68407700, with its registered seat at Jugoslávských partyzánů 1580/3, 16000 Prague 6, Czech Republic, for the purposes connected with the assistance during the application for a travel medical insurance provided by the UNIQA Insurance (UNIQA pojišťovna a.s), VAT: CZ699003142 with its registered seat at Evropská 810/136, 16000 Prague 6, Czech Republic.
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